N.J.A.C. 13:45C-1.3(a)7 requires that all New Jersey licensees provide a timely notice of any change of address from that which appears on the licensee's most recent license renewal or application.

If your MAILING ADDRESS is not current, you will not receive your license renewal form or any other Board mailings. To ensure that you will receive all
Board mailings you must immediately send the Board your current address information.

Be advised that your New Jersey licensing board/committee retains your: Home Address, Business Address and Mailing Address. One of these you determine to be your address of record. Your address of record is the address that will be printed on your renewed license certificate. Your name and this address may also be posted as part of the Online Licensee Directories at: http://www.njConsumerAffairs.gov/director.htm. As a matter of information, under the public disclosure law as it currently stands, any of your license addresses (address of record, home, business and mailing) must be provided if requested under the Open Public Records Act. If you do not indicate an address of record, your mailing address will be considered your address of record. An address of record may be a post office box address, only if another address with a street address is provided.

This change of address form
may be completed and submitted electronically by clicking the "Submit the
Form" button below to meet the address reporting requirement. This form
is for address change reporting only.

Renewal Applications Are Not Forwardedby the Postal Service to a Forwarding Address

* = required fields

Last
Name*:

(as it appears on your license certificate)

First
Name*:

(as it appears on your license certificate)

Two-Letter
License Prefix*:

(i.e. YAXXXXX, YAXXXXX, YBXXXXXX)
The
two letter prefix is found on your license certificate
and precedes your 6-digit license number.)

License
Number*:

(i.e.
YA001200, YA 089890, YB 019980)
The
6-digit license number is found on your license certificate
after the two letter prefix.)

Date of Birth*:

(Use
MM-DD-YY format. The date of birth will be used for verification
purposes only.)

Daytime
Telephone Number*:

(Use 555-555-5555 format. The telephone will be used in the event that questions arise concerning this change of address form.)

E-mail
Address:

Old

mailing address

business address

home address

Street*:

City:

State:

ZIP
Code:

Country:

(if
not U.S.A.)

New
mailing address
Is this your address of record?
Yes
No

Business or Practice Name*:
(if applicable)

Street:

City:

State:

ZIP
Code:

Country:

(if not U.S.A.)

Note: If your mailing address is a business or practice location, you must provide
the business or practice name in order to ensure mail delivery.

New
business address
Is this your address of record?
Yes
No

Business or Practice Name*:
(if applicable)

Street:

City:

State:

ZIP
Code:

Country:

(if not U.S.A.)

New
home address
Is this your address of record?
Yes
No

Street:

City:

State:

ZIP
Code:

Country:

(if not U.S.A.)

Is this your address
of record?
Yes
No(You may only choose one address of record.)

New
home address

Street:

City:

State:

ZIP
Code:

Country:

(if
not U.S.A.)

If you have made a legal name change it is imperative that
this legal name change be reported immediately to the New Jersey
State Certified Psychoanalysts Advisory Committee. You must mail the following items
to the Board office c/o Professional Board Consumer Service
Center, PO Box 45046, Newark, New Jersey 07101.

Your PRINTED former
name,

Your PRINTED new
name,

Your license number
(be sure to include the two-letter prefix with your license
number) AND

A copy of your
marriage certificate, decree of divorce or court order.